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Summary of the impact

Around the world policy initiatives have aimed to increase the engagement
of clinicians in the management of health services and research has shown
that this contributes to improved patient healthcare. Research led by
Professor Ian Kirkpatrick at Leeds University Business School
(LUBS) has identified obstacles to this engagement and proposed ways to
overcome them. The findings have been distilled into training and
educational material which has been delivered to National Health Service
(NHS) staff and guidance which has been used by NHS organisations to
improve practice. Collectively, this work has contributed to improved and
more efficient patient healthcare in several NHS trusts.

Underpinning research

Although research has demonstrated that increased clinical engagement in
the management of health services can contribute to improved patient care,
less is known about how the obstacles to such engagement can be overcome
in practice. This has been the focus of research carried out at LUBS.

The early phase of this research, led by Professors Ian Kirkpatrick
(LUBS, 2000 - present) and Terry McNulty (LUBS, 2000-2006), assessed the
impact of public-management reforms on health service professions. This
research was designed to understand the obstacles to reforms, specifically
those aimed at turning doctors and other professions (such as Social
Workers [1]) into managers [2]. Publications included New
Managerialism and the Service Professions (Kirkpatrick,
Ackroyd and Walker, 2005, Palgrave).

Research by McNulty (with Ewan Ferlie, Imperial College Management
School) also looked at how clinical professionals responded to change and
the difficulties of establishing new hybrid professional-manager roles [3].
The latter were hamstrung by limited resources, inadequate communications
with staff, and the skills of doctors (who often had little prior
knowledge or experience of management).

Building on this work Professor Kirkpatrick then led an inquiry,
commissioned by the Centre for Innovation in Health Management (CIHM) at
the University of Leeds, which was designed to address how obstacles to
greater clinical engagement (elaborated in earlier studies) could be
overcome and therefore how performance itself could be improved.

This Inquiry in 2006 examined the relationship between medicine and
management and the conditions which facilitate more effective working [4].
The research identified specific conditions and policies in an
organisation which supported greater levels of clinical engagement, with
positive results for the efficiency and quality of services.

Building on this work, a second follow on CIHM study in 2008, led by Dr Gianluca
Veronesi and Professor Kevin Keasey (at LUBS, respectively
2006 - present day; 1989 - present day) looked more specifically at
relationships between clinicians and non-clinicians at the board level in
NHS organisations. This also outlined conditions and policies that helped
to overcome obstacles to clinical involvement in decision making and [5]
at how these might enhance performance [6].

The final stage of research is on-going and has extended in two
areas. The first has aimed to deepen understanding of the conditions and
policies that supported clinical involvement in management. A two-year
knowledge transfer partnership (KTP) with Leeds Teaching Hospitals NHS
Trust and NHS Leeds (i) (ii) was followed by a Health
Foundation-funded project (iii) led by Rebecca Malby and Professor
Richard Thorpe (at LUBS respectively, since 2006 and 2003). The
second area of work as been on the relationship between increased clinical
engagement in health services and the impact that this can have on
hospital performance in the EU and non-EU nations. This research work has
been funded by a major EU grant (iv). This research has been
extended to look at the link between clinical leadership and hospital
performance in Australia, Canada and the UK (v).

Details of the impact

This research has been widely disseminated to health professionals in a
number of NHS Trusts through conferences, policy groups, workshops and the
CIHM network. Communication with over 300 top-level decision-makers has
been maintained through CIHM's national network of NHS trusts. Members
have access to the inquiry reports and toolkit (see below), and attend
events, for example publicizing the latest research results on clinicians'
role on NHS trust boards and links with performance. CIHM Director, Becky
Malby, was also recently included as an `eminent thinker' in a meeting
with Sir David Nicholson, NHS Chief Executive for England, which aimed to
discuss the options for NHS reform, including strategies for more fully
engaging doctors (particularly GPs) in managing services. More
specifically, this research has had an impact in two main
ways: through organizational change initiatives and through training and
education.

Organisational Change Initiatives

The two National Inquiries described in Section 2 [4, 5] fed into
the development of a Toolkit for `Developing Productive Relationships
between Management and Medicine'. This toolkit, designed to help overcome
barriers to clinical involvement in management has been used across the
NHS in organisational development projects. The Hertfordshire, Shropshire
and East Riding Primary Care Trusts, for example, used it as part of work
with the CIHM in 2009 and 2010 to improve clinical engagement for
practice-based commissioning. In each, CIHM worked with 20 lead clinicians
and 100 community GPs1 [A]. An online version of the
toolkit - http://www.cihm.leeds.ac.uk/drmgrtoolkit
- is also now available. Since May 2012, a total of 62 NHS trusts and
clinical commissioning groups (CCGs), the NHS Improvement Agency and one
hospice have used it. CIHM maintain a register of toolkit users [B].

CIHM has also worked with Leeds Medical Senate (representing CCGs
locally) to improve clinical engagement. Leeds' three new CCGs are using
the inquiry research to underpin their Commissioning for Quality and
Innovation activity and early results are promising. According to the
Chair of NHS North CCG, "Utilising the University of Leeds National
Inquiry into Management and Medicine...has directly led to robust
relationships being developed...leading to direct improvement in patient
care and more efficient working"[C].

A related initiative (focusing on organisational change) was a Knowledge
Transfer Partnership (KTP) with Leeds Teaching Hospitals Trusts (LTHT)
(2007-10) [D]. Building on the toolkit, this aimed to improve
Clinical Directors' willingness to engage in the leadership of the trust.
The KTP aimed to design and implement a change intervention that would
incentivise clinicians to engage, and lead to improved performance at
individual and directorate levels. The programme was designed and
delivered to approximately half the clinical directors (17 delegates [D]),
with beneficial effects on the trust. The Medical Director of Leeds
Teaching Hospitals NHS Trust said: "The KTP has been immensely useful
for the Trust in moving forward with our strategy of continually
delivering improved levels of service."[E].

Professional Development: Executive Education and Training

The research has been distilled into training and educational courses
which have been delivered to hundreds of NHS staff via different
programmes.

A high profile example of this work is The Darzi Fellows Programme, which
was run by the CIHM in 2009-10 and 2012-13 [F], [G]. This
programme drew extensively on the research from the two Inquiries [4,
5] and included modules focusing specifically on the theory and
practice of clinical management and how to strengthen it. So far the
programme has been completed by over 80 clinical professionals (the
majority being doctors) and the feedback has been outstanding1.
According to one participant: "I truly believe that the energised,
forward-thinking, confident clinician I've become is testament to the
seeds sown and nurtured during my Darzi year"[H].
Participants also reported that their employer benefitted from their
participation in the programme.

In a similar way, the research arising from the Inquiries has fed into
training programmes for other large health organisations. These include: a
2010-11 set of executive education programmes for doctors learning to be
managers (including two for clinical directors at Leeds Teaching Hospitals
NHS Trust, and Rotherham NHS Foundation Trust), the Leeds-wide Senate
Programme (for 26 senior doctors) and a practice-based programme for
commissioning leads (90 GPs)1.

This training has also had an important regional dimension. The toolkit
was utilised by the CIHM in its work with NHS Yorkshire & Humber
(population 5.23 million), specifically the Leading Transformation
Programmes. These have involved 95 senior NHS clinicians and managers
attending two training programmes1. The first (April - March
2012) helped senior professionals communicate ideas and change within
their organisation, focusing in particular on how obstacles to clinical
engagement with management could be overcome. The second (April - November
2012) had a similar focus, although targeted to the specific policy
context of the management of services for people with long term conditions
[I].

The feedback received from practitioners has been excellent. A Senior
Leadership and Organisation Development Consultant of Health Education
Yorkshire and Humber said: "There is considerable evidence that this
research and the resulting knowledge transfer and engagement with
practice has greatly benefitted the NHS by bringing about the means to
improve services for the good of our patients."[I].
Evaluations from these programmes also show a new, more effective
relationship being formed between doctors and managers, changing attitudes
and generating service improvements [I].

This research has had an impact in the upper echelons of the NHS
elsewhere in the north of England, having been distilled into training
programmes which were delivered in partnership with the NHS North West [J].
The CIHM utilised the findings of the two national inquiries and
incorporated them into a series of Board Level Director Leadership
Programmes. Around 300 NHS Directors (including aspiring chief executives)
participated in these events1. The NHS has confirmed
that the course helped facilitate interpersonal relationships and improve
communication between doctors and managers, gave staff the tools to better
understand their organisation, and proposed methods to enable leaders to
bring about organisational change more effectively. The Director of NHS
North West Leadership Academy said: "We are confident to say that from
the evidence gathered, the Directors' leadership programmes have had a
positive and lasting effect on the delivery of healthcare in the North
West region."[A].

[J] NHS North West Leadership Academy, Interim Report on Findings
from Research into the Effectiveness of Academy Programmes, Report by
Aston Business School, October 2011, see all references to Work Stream 3
which was delivered by Leeds.